How on God’s good earth does a G6(3+3) biopsy get upgraded to a G9(5+4) post op?

PSA3, great question. I've seen various numbers quoted, that somewhere between 20 and 40% of biopsies are upgraded on surgical pathology. I'm one. I went from 3/12 cores, all on one side of the prostate, to 15-20% total involvement on all 4 quadrants, and from G6 to G7.

Reality is that the standard TRUS 12 core biopsy only 'gets' something like 1/10 of 1 % of the prostate. The transperineal biopsy with 30-40 cores is much, much better.

Again, let's get better diagnostic tools.

PSA3DOT7 said...
I have not had time to respond to an article about a person, here some two to three weeks ago, who was initially diagnosed with a G6 and opted to have an operation. When his post op diagnostics came back he was upgraded to a G9. I think he phrased it that he felt that he had just “dodged a bullet”.

Is a biopsy such a massive game of chance? And what does such an outcome mean to others who are told that they only have a G6 and have all the time in the world to make a treatment decision?

Yes, it does seem that there is quite an element of chance. When I have made my argument to G6 folks to take their time and consider all options including AS, I have usually said something along the lines of "sure, it is possible you have a G9 in there". And we in fact do know that X % will be upgraded at least a small amount, and probably an equal or smaller # will be downgraded. I was, from the bad 5+4 G9 to the really, really great 4+5 G9.

But the way it seems to me, and considering the potential- even likely- negatives of treatment, it seems to me that I just have to go by the known, i.e. what the Bx shows. Before any of us ever has a Bx, any one of us could have a G10 cooking away in there, and in fact some of us do. but we don't volunteer for possible impotence and incontinence and more just because we are a 40+ year old male, who has a prostate, which theoretically could not only have PC but even a G10.

Unless someone has statistics: if you have say small volume G6 PC, are you significantly more likely to also be harboring an undiagnosed G8-10 compared to someone who has not even had a Bx yet? If they(G6s) do have a significantly higher risk compared to the general population, I'm not sure how we can tell folks they have plenty of time and maybe should do AS for a while. Because there is no way to know what might be hiding in there except to cut the prostate out of it's happy home and look at it in the lab. There is no way to know this about either a Bx'ed G6 or someone who has not even had a Bx. If you are a male with a prostate, then you might be G10. None of us will ever know for sure unless we cut the gland out of there.

But if we are going to cut it out of there only so we can know it is truly only a G6, then it could be argued that we should do that for all adult males. But of course we don't, so we just have to go by what the Bx shows when deciding what kind of treatment. Sadly, for (I suppose) a very small % of us, that is going to work out badly.

That was me who went from 6 to 9. I see the doc again in 2 weeks and my first question will be what % of the time do they see that significant a change. Perhaps I should be buying lottery tickets! Coming on 4 weeks post RALP and recovery going pretty well. Pathology showed it was contained; so sure hoping & praying for favorable PSA (blood draw is next week).

PSA3,

This is not at all unheard of. As halbert said approx. 20%-40% of biopsy results are upgraded after surgery. "You don't know what you've got until it's gone." You know that song....

You have been here long enough to have seen this happen quite often. This sort of situation is what adds to the debate of "does PCA mutate into higher Gleason scores overtime or is someone on AS just under graded."

When you look at AS mortality stats., I have always wondered why they don't consider the fact that many men are under graded on biopsy. To me that means that many, many men approx. 20%-40% on AS have higher Gleason scores than 3+3=6 and survive for a very, very long time on AS. It tells me that some PCA no matter what the Gleason score is don't progress and expected. You see that with some men here.

This should not come as a shock to you.....You know that a biopsy on samples a very small amount of the gland and the post-op pathology gives a little better picture, although not complete it is better.

halbert said...


Again, let's get better diagnostic tools.

Actually, some excellent diagnostic tools DO exist in the form of a multi-parametric MRI. In my opinion, anyone considering AS should have one done and read by an expert. These are very good at identifying more aggressive tumors that can then be biopsied and treated as necessary. Without this, the G6 diagnosed man on AS is simply watching his PSA and waiting for the next biopsy to see if higher grade PCa is found.

Jim

This is a major reason I chose not to go the AS route, even though it was offered as a possible option to me. I had a total of 3 readings of my biopsy slides and they were pretty consistent in their opinions.

I was diagnosed a GL 7, who just might be able to go the AS route. But it seems frequently enough that post surgery analysis results in a score upgrade. I chose radiation so there was no actual chance to re-evaluate in my case and up or downgrade my score.

As usual, wise words from Allen.

I wondered, like a lot of us who didn't get a second opinion, about my biopsy... a G7 but a 4+3 with PNI. Was it too low? Too high? Still, it's a nagging thing, considering it was only 20 cores. Guess it doesn't matter now that treatment is done.

WRT the 3 options outlined by Allen, I assume I will never know the reason for the big change. My URO is a fairly large practice here in Orlando so would like to believe bx they pull are diagnosed by experienced pathologists. And 24 cores were emamined. Unfortunately, I didn't join HW until a few weeks ago so wasn't aware of the advice found here to seek second opinions. That said, I appreciate all who have weighed in to help me try to understand how it can happen. And thanks for the comforting words Special Lady.

Jim - how would I actually do that? Do I ask my URO to send the slides with a request? Do I get the slides and send / make the contact? Does insurance usually pay for second patholovy? Thanks for any insight.

I actually just noticed on the Johns Hopkins website they say that insurance and Medicare do not cover the second opinion.

Newgrange, not to discount the G9 pathology at all, but I'd suggest that it is hugely significant that your margins are clear. No ECE, no SVI. That is a big deal. You still need to be watchful with regular PSA's and other checks into the future, perhaps more vigilant than those of us who didn't go up that high...or perhaps not...my G7 is considered the flaky one.

Yeah, going from G6 to G9 is scary and challenging. Having it fully contained almost....note the almost...makes it an academic point. When are you due for your first PSA?

First post-surgery blood will be drawn this week (31 days after surgery) and see the Dr next week for results. From what I read here on HW, that may be a bit soon but trust the Dr knows why he's asking for it at this point. Thanks to all for weighing in on this.